Instructions

Substitute all words in blue with the factual information concerning the birth of your child. Eliminate as many underlines as practical. This 'form' is simply an idea in creating your own. If, at some point in the future, your child want to be in the system or obtain a passport, your notarized certificate of live birth will be sufficient to prove the fact that your child was born in this country. The reason you may want a witness on your certificate of live birth is because, in the event your child wants to opt into their system, the state will request the written testimony of a witness if you do not put one on your certificate of live birth.

Certificate of Live Birth

I, Father's full name , and my wife, Mother's full name, gave birth to

Child's full name on Month, Day, Year at TimeEastern Standard Time.

Ourdaughter/son, Child's full name , was born in our home at Street Address, City, State.

She/he was weight andlength (21 inches) at birth and is perfect in every way, a true miracle of God's Creation.

Signature________

Print Father's Name

__Signature__________

Print Mother's Name

Signature________

Witness - Print Witness's Name

Subscribed and sworn to before me this _______ day of _________, __________.